DeLand Chiropractic & Spinal Decompression New Patient Application

The information that you will provide on this form will play a key role in determining your ability to be accepted as a patient in this office. Your qualification as a patient is determined by the nature of your injury, the doctor’s ability to treat your condition, your commitment to getting well, your family and/or spousal support, your ability to pay for recommended care, and your willingness to make sacrifices to ensure your proper healing. Please be sure that you answer all questions. Thank you – Dr. Gordon’s Staff.

Name: ______Sex: M F Marital Status: S M D W Address: ______City:______State: ______Zip Code: ______Date of Birth: ______SSN: ______Home Phone: ______Work Phone: ______Cell Phone:______Employer: ______Occupation: ______Age:______Email:______Hobbies:______Name Of Your Medical Doctor And May We Contact Them?:______Y N Race: ______Ethnicity: ______Are Your Pregnant? Y N How Did You Hear About Our Clinic: ______Preferred Language:______Emergency Contact Name & Phone #: ______Relation:______------What Is Your Chief Complaint? ______Date Of Your Injury? ______Work Related? Y N Auto Accident Related? Y N Have Had Chiropractic Care Before? Y N How About Acupuncture? Y N ------Do You Smoke Cigarettes? Y N Currently? Y N Formerly? Y N Never? Do You Drink Alcohol? Y N If Yes, How Often?______How Much? ______Do You Use Recreational Drugs? Y N What Type?______------Do You Have A Family History Of: (check all that apply) Heart Disease Arthritis Hypothyroid Diabetes ( Type I Type II) Seizures Stroke Osteoporosis Rare Genetic Disease (type) ______Cancer (type) ______------Do You Have A Past Medical History Of: (check all that apply) Lower Back Pain Stroke Thyroid Disease Diabetes ( Type I II) Sciatic Pain Birth Control Pills Auto Accidents Hormone Replacement Hypertension Head Trauma Heart Attack Osteoporosis Neck / Back Trauma Blood Clots Balance Problems Dizziness Cancer (type)______Numbness On ½ Of Your Face or Body

Please List Any Allergies, Surgeries, Accidents, Falls, Pregnancies, Or Hospitalizations: ______List All Medications & Dietary Supplements That You Are Taking (List Dosage & Frequency): ______------If the doctor recommends a treatment plan to correct or manage your condition, are you willing to make small sacrifices (changing diet, exercise, change habits) in order to receive care in our office? Yes No

If your health insurance (if applicable) does not cover 100% of your proposed care, are you willing to make a personal financial investment in your own health in order to get well and improve your health? Yes No

IF YOU HAVE ANY QUESTIONS OR CONCERNS WITH THE INFORMATION BELOW, IT IS YOUR RESPONSIBILITY TO ADDRESS THOSE CONCERNS WITH THE DOCTOR. Informed Consent, Financial Responsibility, and Assignment of Benefits: As with all medical or chiropractic treatments, I acknowledge and understand that there are inherent risks to receiving care including but not limited to sprains, strains, fractures, dislocations, muscle pain, bruising, and stroke. Statistically, these risks are extremely rare and uncommon (1 in 1 – 5 million in the case of strokes), especially when compared to those risks related with alternative treatment options for my condition including the use of over the counter analgesics, prescription drugs, and surgery. Due to that fact, I will not hold the physician or staff responsible for those risks listed above. In addition, I understand that the risk and danger of allowing my condition to go untreated may lead to further deterioration of my condition with possible serious and/or permanent consequences to my health. I acknowledge and understand that the use of certain prescription medications (i.e. birth control pills, hormone replacement, aspirin, Coumadin), illicit drug or alcohol use, and cigarette smoking may increase these risks and inhibit proper healing. I also understand that if I am accepted as a patient, and if I receive care, that I am the ultimate responsible party on my account regardless of the actions of any 3rd party carrier (insurance company). I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, attorney fees, court costs, collection agency fees, and interest at the rate of 18% per annum(1.5% per month). By signing below, I also agree to allow the doctor to share any and all medial reports and findings with my primary care physician, and I allow the doctor to use my name and case history in monthly newsletters and/or patient testimonial booklets. Lastly I understand that any physician at DeLand Chiropractic & Spinal Decompression can not evaluate, examine, x-ray, diagnose, or treat me for my presenting condition without my signature below. By signing below I acknowledge that I have weighed the risks versus benefits of treatment, and I give the doctor consent to treat me for my condition.

Print Name:______Date:______

Signature: ______Name: ______Date: ______Auto Accident Details: 1. Were you the □ driver □ front seat passenger □ rear seat passenger □ motorcycle rider 2. The make of the vehicle that you were in during the accident was a ______3. The make of the other vehicle involved in the accident was a ______4. Your estimated speed at the time of the accident was ______5. The time of day of the accident was □ daytime □ dawn □ dusk □ dark 6. Road conditions at the time of the accident were □ dry □ wet □ snow □ ice 7. Were you wearing a seatbelt at the time of the accident? □ yes □ no Did an airbag deploy? □ yes □ no 8. Was your head turned at the time of the accident? □ yes □ no 9. If you were the driver, was your foot applied on the brake at the time of the accident? □ yes □ no 10. Did you strike any part of the interior of the vehicle during the accident? □ yes □ no 11. Did you lose consciousness as a result of the accident? □ yes □ no If yes, how long? ______12. Was a police report made at the accident scene? □ yes □ no Who was found to be “at fault”? ______13. Estimated property damage to your vehicle ______14. After the crash did you go □ home □ emergency room. Mode of transportation? ______15. What were your primary symptoms after the accident? ______16. Have you seen any other physicians or received treatment for your injuries anywhere else? □ yes □ no If yes, where? ______17. Please describe and diagram your accident below:

Please mark the figures below with the letters that best describe the sensation or pain you are feeling. Please mark areas where pain radiates or spreads with a ↑, ↓, or ←, → arrow to indicate the direction of radiating pain. (Include all affected areas)

>>> Ache XXX Burning - - - - Throbbing === Numbness /////// Stabbing oooo Pins & Needles

Severity of Pain List region of pain and circle severity (1=least, 10=greatest)

1.______1 2 3 4 5 6 7 8 9 10

2.______1 2 3 4 5 6 7 8 9 10

3.______1 2 3 4 5 6 7 8 9 10

4.______1 2 3 4 5 6 7 8 9 10

Name______Date ______Instrumental Activities of Daily Living Scale (I.A.D.L.) Choose the option below that best describes your ability:

1. Ability to use the telephone: 2. Laundry: a. Operates telephone on own initiative. Able to a. Does personal laundry completely. look up and dial numbers, etc. b. Launders small items. b. Dials a few well-known numbers. c. All laundry must be done by others. c. Answers telephone, but does not dial. d. Does not use telephone at all.

3. Shopping: 4. Mode of transportation: a. Takes care of all shopping needs independently. a. Travels independently on public transportation or b. Shops independently for small purchases. drives own car. c. Needs to be accompanied on any shopping trip. b. Arranges own travel via taxi, but does not otherwise d. Completely unable to shop. use public transportation. c. Travels on public transportation when accompanied by another. d. Travel limited to taxi or automobile with assistance of another. e. Does not travel at all.

5. Food Preparation: 6. Responsibility for own medications: a. Plans, prepares and serves adequate meals a. Is responsible for taking medication in correct independently. dosages at correct time. b. Prepares adequate meals if supplied with the b. Takes responsibility if medication is prepared in ingredients. advance in separate dosage. c. Heats, serves and prepares meals or is able to prepare c. Is not capable of dispensing own medication. meals, but does not maintain adequate diet. d. Needs to have meals prepared and served.

7. Housekeeping: 8. Ability to handle finances: a. Maintains house alone or with occasional assistance. a. Manages financial matters independently b. Performs light daily tasks such as dish washing, bed (budgets, check writing, etc. making, etc. b. Manages day-to-day purchases, but needs help c. Performs light daily tasks unsuccessfully. with major purchasing, etc. d. Needs help with all home maintenance tasks. c. Incapable of handling money. e. Does not participate in any housekeeping tasks.

Katz Basic Activities of Daily Living (ADL) Scale

Check “yes” if you are able to do the task independently or “no” if you areYES unable.NO – – 1. Bathing Able– to bath without assistance. 2. Dressing Able– to dress without assistance. 3. Toileting Able– to use toilet or urinal without assistance. 4. Transferring– Moves in and out of bed or chair alone. 5. Continence Controls bowel and bladder completely by self 6. Feeding Feeds self without assistance.

PAIN DISABILITY QUESTIONNAIRE

Patient Name ______Date______

Instructions: These questions ask your views about how your pain now affects how you function in every day activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

1. Does your pain interfere with your normal work inside and outside the home?

��� � � � � � � � � � � � � � � �� � � � � � � �� � � �� � � � � � � �� � � � � � Work Normally Unable to work at all 0 1 2 3 4 5 6 7 8 9 10 2. � � � Does � � � � � � your pain � � � � � � � interfere � � � � � � with � � � � � � � personal � � � � � � � care (such � � � � � � � as washing, � � � � � � � dressing, � � � � � � � etc.)? � � � � � � � � � � �� � � Take care of myself completely Need help with all my personal care 0 1 2 3 4 5 6 7 8 9 10 3. � � � Does � � � � � � your pain � � � � � � � interfere � � � � � � with � � � � � � � your traveling? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Travel anywhere I like Only travel to see doctors 0 1 2 3 4 5 6 7 8 9 10 4. � � � Does � � � � � � your pain � � � � � � � affect � � � � � � your abilit � � � � � � �y to sit � � � � � � � or stand? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � No problems Can not sit/stand at all 0 1 2 3 4 5 6 7 8 9 10 5. � � � Does � � � � � � your pain � � � � � � � affect � � � � � � your ability � � � � � � � to lift � � � � � � � overhead, � � � � � � � grasp objects � � � � � � � or reach � � � � � � � for � � � � � � �things? � � � � � � � No problems Can not do at all 0 1 2 3 4 5 6 7 8 9 10 6. � � � Does � � � � � � your pain � � � � � � � affect � � � � � � your abi � � � � � � �lity to lift � � � � � � � objects off � � � � � � � the floor, � � � � � � � bend, stoop � � � � � � � or squat? � � � � � � � � � � � � � � No problems Can not do at all 0 1 2 3 4 5 6 7 8 9 10 7. � � � Does � � � � � � your pain � � � � � � � affect � � � � � � your ability � � � � � � � to walk � � � � � � � or run? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � No problems Can not walk/run at all 0 1 2 3 4 5 6 7 8 9 10 8. � � � Has � � � � � � your income � � � � � � � dec � � � � � � lined since � � � � � � � your pa � � � � � � �in began? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � No decline Lost all income 0 1 2 3 4 5 6 7 8 9 10 9. � � � Do � � � � � � you have � � � � � � � to take pain � � � � � � medication � � � � � � � every � � � � � � � day to � � � � � � � control � � � � � � �your pain? � � � � � � � � � � � � � � � � � � � � � No medication needed Need medication throughout the day 0 1 2 3 4 5 6 7 8 9 10 10. � � � Does � � � � � � your � � � � � � � pain force � � � � � � you to � � � � � � �see doctors � � � � � � � much more � � � � � � � often � � � � � � � than before � � � � � � � your � � � � � � �pain began? � � � � � � � Never see doctors See doctors weekly 0 1 2 3 4 5 6 7 8 9 10 11. � � � Does � � � � � � your � � � � � � � pain interfere � � � � � � with � � � � � � � your ability � � � � � � � to see � � � � � � � the people � � � � � � � who are � � � � � � � important � � � � � � � to you? � � � � � � � No problem Never see them 0 1 2 3 4 5 6 7 8 9 10 12. � � � Does � � � � � � your � � � � � � � pain interfere � � � � � � with � � � � � � � recreational � � � � � � � activities � � � � � � � and � � � � � � � hobbies? � � � � � � � � � � � � � � � � � � � � � No interference Total interference 0 1 2 3 4 5 6 7 8 9 10 13. � � � Do � � � � � � you need � � � � � � � the help � � � � � � of your � � � � � � � family and � � � � � � � friends � � � � � � � to complete � � � � � � � everyday � � � � � � � tasks? � � � � � � � � � � � � � � Never need help Need help all the time 0 1 2 3 4 5 6 7 8 9 10 14. � � � Do� � � � � � � you now � � � � � � � feel more � � � � � � depressed, � � � � � � � tense, � � � � � � � or anxious � � � � � � � than � � � � � � �before your � � � � � � � pain began? � � � � � � � � � � � � � � No depression/tension Severe depression/tension 0 1 2 3 4 5 6 7 8 9 10 15. � � � Are � � � � � � there em � � � � � � �otional � � � � � � problems � � � � � � � caused � � � � � � � by your pain � � � � � � � that interfere � � � � � � � with � � � � � � � your � � � � � � � family, social � � � � � � � and or work activities? No problems Severe problems 0 1 2 3 4 5 6 7 8 9 10

DeLand Chiropractic & Spinal Decompression Dr. Jeremy M. Gordon & Dr. Michael Munson

905 North Stone Street Phone (386)734 -9995 DeLand, FL 32720 Fax (386)734-9949

Nutritional Counseling DRX Spinal Decompression Chiropractic Acupuncture Comprehensive Blood Analysis

ASSIGNMENT, LIEN AND AUTHORIZATION OF BENEFITS

I,______, hereby authorize and direct you, my insurance company, and/or attorney, to pay directly to DeLand Chiropractic and Spinal Decompression such sums as may be due and owing this office for services rendered me, both by reason of accident or illness, and by reason of any other bills that are due this office, to withhold such sums from any disability benefits, medical payments benefits, “no-fault benefits”, health and accidental benefits, workmen’s compensation benefits, or any other insurance benefits obligated to reimburse me or from my settlement, judgment or verdict on my behalf as may be necessary to adequately project this office. I hereby further give a lien to said office against any and all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness from which I have been treated by this office. Signature of this document authorizes the release of any medical or other information necessary to process this claim, and I request payment of government benefits and authorize payment of medical benefits to the undersigned physician or durable medical goods supplier for goods or services provided. This is to act as an assignment of my rights and benefits to the extent of the office’s services provided.

In the event my insurance company which is obligated to make payments to me for the charges incurred at this office refuses to make such payments, upon demand of this office, I hereby assign and transfer to this office any and all causes of action that I might have or that might exist in my favor against such company and authorize this office to prosecute said cause of action either in my name or in the office’s name and further I authorize this office to compensate settle or otherwise resolve said claim or cause of action as they see fit.

DeLand Chiropractic and Spinal Decompression accepts the aforesaid assignment and hereby notifies any insurer issuing payment that DeLand Chiropractic and Spinal Decompression objects to any repricing or reduction of billed amounts unilaterally made by any insurer. Any such reduced payments issued by any insurer are accepted under protest and without waving any right of the provider to pursue all legal remedies against the insurer.

I, ______, understand that I remain personally responsible for the total amounts due the office for their services that are not paid by the insurance company.

I, ______, authorize the office to release any information pertinent to my case to any insurance company, adjuster or attorney to facilitate collection under this assignment, lien and authorization. I agree that the above-mentioned office be given power of attorney to endorse/sign my name on any and all checks for payment of my doctor (medical) bill.

Please read this document completely before signing. If you do not understand this document or have any questions about this document, please ask us to explain it to you. If there is any portion of this document that you do not wish to authorize, we will remove that portion from this document. Your signature below is your agreement you fully understand this document and you fully agree to the terms of this document.

______Patient or guardian’s signature Date

______Witness to patient or guardian’s signature Date DeLand Chiropractic & Spinal Decompression Dr. Jeremy M. Gordon & Dr. Michael Munson

905 North Stone Street Phone (386)734 -9995 DeLand, FL 32720 Fax (386)734-9949

Nutritional Counseling DRX Spinal Decompression Chiropractic Acupuncture Comprehensive Blood Analysis

Medical Records & Privacy Practices

Release and Receipt of Medical Records

I, ______, hereby authorize DeLand Chiropractic and Spinal Decompression to release any information contained in my medical records file to another physician, my attorney, my insurance company and/or my immediate family on my behalf. I understand that I may revoke this release of records at any time by notifying DeLand Chiropractic and Spinal Decompression in writing. I also hereby authorize DeLand Chiropractic & Spinal Decompression to acquire copies of my medical records from other physicians. Further, I agree that a copy of this authorization may be used in place of the original.

______Patient Signature Date

Acknowledgement of Receipt of Notice of Privacy Practices

I, ______, acknowledge that DeLand Chiropractic and Spinal Decompression has issued or offered to issue me a copy of the Notice of Privacy Practices. This notice describes how medical information about me may be used and disclosed and how I may obtain access to this information. With my signature below, I am acknowledged such receipt.

______Patient Signature Date